Trauma: The Paradigm for Medical Care in the 21st Century

It has been one of my greatest honors to serve as your President for the last two years. However, I also remain greatly saddened by the devastating events that caused the cancellation of our meeting last year. The resilience and determination of our country was indeed tested, but we have demonstrated our strength of will and our drive to go forward; and that we will, I am sure. For those of you who missed the opportunity to visit Seattle, I begin with a view of Harborview Medical Center, located in a landscape quite different from our current surroundings. Much of what I will present is based on my experiences at this Level I Trauma Center, not because it is better than the other excellent centers at which you work, but because I know trauma care most completely as it is practiced at this institution. In addition, I must recognize a role model whom has meant so much to me and to so many others in the field of trauma. Dr. C. James Carrico was an early and critical mentor who influenced every aspect of my career, from the selection of trauma as a career to his prodding me into a postdoctoral fellowship in inflammatory cell biology to guidance as a budding academic trauma surgeon and intensivist in his role as Chief of Surgery at Harborview Medical Center and, forever, my “Chief”. He was the most dedicated, thoughtful, compassionate, and caring academician with whom I have had the privilege to work. I thank him for all he so willingly gave to me, and I dedicate this presentation to his memory (Fig. 2). Fig. 2: Dr. C. James Carrico.Is trauma the paradigm for medical care in the 21st Century and, if it is, how did we get here? What have we accomplished? Where have we failed, and where should we go? Trauma care has come far in this country, arising from a scattering of isolated “county hospitals” left over when these large urban institutions became too expensive to maintain as societal safety nets for the “poor people.” However, while direct societal support disappeared, the people kept coming and the hospitals stayed full. Many had severe injuries and many had no money; both required care that was not available elsewhere, so the institutions persisted, primarily in the large urban settings. These institutions, in large part by default, became increasingly dedicated to the care of the injured. As these institutions grew in stature as leaders in the care of the critically injured, they became more and more alienated from the developing mainstream of modern elective surgical specialty care. Although the elective “insured” patient increasingly avoided these institutions, their place in the health care system has always been recognized, although never fully appreciated, unless they have threatened to close. As with previous armed conflicts, the Vietnam War in the late 1960s contributed major advances in the care of the severely injured, including demonstration of the benefit of well-organized prehospital care and rapid delivery to definitive care. In Miami, for cardiac disease, and a year later in Seattle, for cardiac and, for the first time, trauma, citywide organized EMS systems were created. While Dr. David Boyd, in Illinois, attempted to create the first statewide trauma system, Dr. R. Adams Cowley in Baltimore achieved a unique political success in centralizing trauma care in the state of Maryland with a dedicated Shock Trauma Institute at its core, supported by line item funding. Later, in the 1970s, on the West Coast, the seminal studies published by West and Trunkey, comparing trauma outcomes between San Francisco and Orange County, demonstrated a reduction in unnecessary deaths from >30% to <5% in dedicated trauma centers. 1 This work has been reproduced in numerous studies, including our own in the Northwest, confirming that a regionalized trauma system with triage criteria and dedicated trauma centers reduces the potentially preventable mortality rate to the apparent minimum of 1 to 3%. 2 This is a laudable success of trauma-initiated self-improvement that began over 20 years before the recent Institute of medicine (IOM) recommendations based on the estimates of nearly 100,000 unnecessary deaths in the medical system annually. Trauma care providers should be proud. Trauma is not only the first specialty to self-assess how care can best be delivered, but importantly, also self-imposed a tiered triage system and regionalized care. While the process has been long, halting, and far from complete, the drive to provide the best care possible for our patients has endured. Currently, according to the recent Trauma Information Exchange Program (TIEP) survey sponsored by the American Trauma Society, 35 states have implemented designation/verification by a state or regional central authority with mandated triage guidelines (Fig. 3). Within these state systems, the network of dedicated trauma centers has continued to grow to over 1000, although only a minority of centers have undergone review by the Verification Committee of the American College of Surgeons’ (ACS) Committee on Trauma (COT). As an example of a state system based on demographics and patient need, the State of Washington has an inclusive system involving 73 of the 94 health care facilities in the state but limits the level of designation to patient needs, not political wants. Similarly, King County and Seattle contain a single Level I and several Level III and IV trauma centers to ensure access to care for all. There are no other Level I or IIs in this area in direct competition, and thus, regionalization of care occurs (Fig. 4). Nonetheless, the proof of principal has not been easy. 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